One hundred and sixty-seven patients with adolescent idiopathic scoliosis were allocated prospectively to one of three different groups for correction before undergoing posterior spinal fusion and Harrington instrumentation, In group 1 single curves were corrected by a Risser turnbuckle plaster jacket and double curves by halo-pelvic traction. In Group 2 patients performed Cotrel dynamic traction for three weeks and this was followed by correction in a plaster cast. In Group 3 patients were given Cotrel dynamic traction for one week only and the operation was performed without a plaster cast. There was no significant difference in the overall correction achieved among the patients in the three groups except that double curves corrected slightly better in Group 2. The correction achieved by Cotrel dynamic traction after three weeks was not significantly different from that obtained at 48 hours. An anteroposterior radiograph of the spine taken during Cotrel dynamic traction was a valuable guide to the mobility of the curve and is preferable to radiographs of the patients bending laterally, particularly with respect to curves over 70 degrees. The paper concludes that correction before operation is not required routinely in adolescent idiopathic curves unless the deformity is a severe and rigid one in which case a radiograph during Cotrel traction is a useful assessment

1. The incidence of osteogenic sarcoma, chondrosarcoma and Ewing's sarcoma in relation to age, sex and site is analysed in a study of 832 malignant primary bone tumours diagnosed in Sweden in 1958-68. The results are compared with those in other series. 2. The adolescent incidence peak for osteogenic sarcoma is caused by tumours localised to the long bones of the lower limb. The peak incidence occurs at a mean age of twelve years for girls and sixteen years for boys and is associated with the maximum growth velocity for the adolescent growth spurt. 3. Ewing's sarcoma, showing no sex difference with regard to its incidence peak, seems not to be associated with bone growth. 4. In the adult, the incidence of osteogenic sarcoma parallels that of chondrosarcoma, thus showing a successive increase with increasing age. In Sweden, where Paget's disease is uncommon, the incidence of osteogenic sarcoma over the age of thirty is only one-third of that during adolescence. 5. In osteogenic sarcoma and chondrosarcoma but not in Ewing's sarcoma, the characteristic predominance of males over females is valid only for localisations to the long bones of the lower limb, the pelvis and the spinal column and not for other sites. Internal factors such as age, sex, bone growth and maturation and also weight-bearing seems to be of importance in modifying the response of the tissue to a causative external factor, like a common virus

1. The production of scoliosis in young animals by resection of the posterior ends of the ribs is described and the etiological mechanisms discussed. It is suggested that retardation of posterior rib growth, removal of mechanical support from one side of the spine, and disturbance of proprioceptive impulses are the factors which initiate the deformity. 2. Some or all of these mechanisms may contribute to the production of certain human curves, for instance impaired rib growth and support in post-poliomyelitic deformities, proprioceptive and reflex disturbances in syringomyelia. 3. Therapeutically resection of the heads and necks of the ribs on the concave side of thoracic idiopathic curves is followed by improvement in some cases. Exactly how much improvement, in what proportion of curves, and for how long it will be maintained cannot be defined at present, but therapeutically worthwhile effects have been obtained, especially in children under five years old; even if this improvement is followed by later progression, several years of freedom from bracing may have been achieved, and the operation has not in any way interfered with subsequent correction and posterior fusion if this has seemed necessary. It is thought that this operation may have a small but useful role in the early management of idiopathic scoliosis, especially in a young child who is not responding well to bracing

Aims

Accurate placement of the acetabular component is essential in total hip arthroplasty (THA). The purpose of this study was to determine if the ability to achieve inclination of the acetabular component within the ‘safe-zone’ of 30° to 50° could be improved with the use of an inclinometer.

Aims

Lumbar fusion is known to reduce the variation in pelvic tilt between standing and sitting. A flexible lumbo-pelvic unit increases the stability of total hip arthroplasty (THA) when seated by increasing anterior clearance and acetabular anteversion, thereby preventing impingement of the prosthesis. Lumbar fusion may eliminate this protective pelvic movement. The effect of lumbar fusion on the stability of total hip arthroplasty has not previously been investigated.

Aims

The aims of this study were to describe the prevalence of previous lumbar surgery in patients who undergo total hip arthroplasty (THA) and to investigate their patient-reported outcomes (PROMs) one year post-operatively.

Of the 4172 patients in a survey of all cases of tuberculosis notified in a six-month period in England and Wales in 1978-79, 198 had a bone or joint lesion; 79 were white and 108 were of Indian subcontinent (Indian, Pakistani or Bangladeshi) ethnic origin. The estimated annual notification rates for orthopaedic tuberculosis were 29 per 100 000 for the Indian subcontinent group and 0.34 per 100 000 in the white group, a ratio of 85 to 1. Rates increased with age in both groups. The spine was the most common site, and was affected in 30% of the white patients and 43% of the Indian subcontinent patients; the distribution of other sites was similar in both groups. Positive culture from a bone or joint lesion was obtained in 99 (50%) of the 198 patients (58% of white patients and 47% of the Indian subcontinent patients). Bacteriological or histological confirmation of tuberculosis either from a bone or joint lesion or from another site was obtained in 68% of the patients. Mycobacterium tuberculosis was isolated from the orthopaedic lesions in 79 of the 82 patients with identification test results and M. bovis in the 3 remaining patients. Of the 61 patients with M. tuberculosis and with no history of previous chemotherapy, 5 had resistant strains compared with 1 of the 18 patients who had previously received chemotherapy. All 6 patients with resistant strains were of Indian subcontinent ethnic origin

Aims

To evaluate the incidence of primary venous thromboembolism (VTE), epidural haematoma, surgical site infection (SSI), and 90-day mortality after elective spinal surgery, and the effect of two protocols for prophylaxis.

Objectives

The Precice nail is the latest intramedullary lengthening nail with excellent early outcomes. Implant complications have led to modification of the nail design. The aim of this study was to perform a retrieval study of Precice nails following lower-limb lengthening and to assess macroscopical and microscopical changes to the implants and evaluate differences following design modification, with the aim of identifying potential surgical, implant, and patient risk factors.

Aternatives to autogenous bone graft for spinal fusion have been investigated for many years. It has been shown that osteoconductive materials alone do not give a rate of fusion which is comparable to that of autogenous bone graft. We analysed the effectiveness of porous ceramic loaded with cultured mesenchymal stem cells as a new graft material for spinal fusion in an animal model. Posterolateral fusion was carried out at the L4/L5 level in 40 White New Zealand rabbits using one of the following graft materials: porous ceramic granules plus cultured mesenchymal stem cells (group I); ceramic granules plus fresh autogenous bone marrow (group II); ceramic granules alone (group III); and autogenous bone graft (group IV). The animals were killed eight weeks after surgery and the spines were evaluated radiographically, by a manual palpation test and by histological analysis. The rate of fusion was significantly higher in group I compared with group III and higher, but not significantly, in group I compared with groups II and IV. In group I histological analysis showed newly formed bone in contact with the implanted granules and highly cellular bone marrow between the newly formed trabecular bone. In group II, thin trabeculae of newly formed bone were present in the peripheral portion of the fusion mass. In group III, there was a reduced mount of newly formed bone and abundant fibrous tissue. In group IV, there were thin trabeculae of newly formed bone close to the decorticated transverse processes and dead trabecular bone in the central portion of the fusion mass. In vitro cultured mesenchymal stem cells may be loaded into porous ceramic to make a graft material for spinal fusion which appears to be more effective than porous ceramic alone. Further studies are needed to investigate the medium- to long-term results of this procedure, its feasibility in the clinical setting and the most appropriate carrier for mesenchymal stem cells

1. In this series of posterior onlay grafting with fresh autogenous bone and without internal fixation, in the treatment of non-infective structural lesions in the lumbo-sacral area, 71 per cent of the patients were relieved of their symptoms, but bony fusion was obtained in only 60 per cent. 2. It is probable that with this technique twelve weeks' immobilisation in a plaster bed is required. 3. Some failures are ascribed to the use of an insufficient quantity of bone or to poor apposition of the graft to its bed. 4. It is evident that the more vertebrae one attempts to fuse the more difficult it is to succeed. When the diseased area is successfully fused but an unnecessarily long graft has been used, a pseudarthrosis above the level of the pre-operative pathology may be the cause of persisting backache. For these reasons we believe that one should not attempt to graft more vertebrae than is necessary to stabilise the local lesion. 5. The complication rate, particularly from deep vein thrombosis, was high. This major complication could perhaps be overcome by using banked bone. 6. The indications for the operation are assessed as follows. It should be done for low back pain only when there is a definite diagnosis and a limited extent of structural pathology; one can then expect excellent results when successful fusion is achieved and also an appreciably high proportion of satisfied patients even when bony fusion has not been obtained, presumably because there is a fibrous union strong enough to stabilise the affected spine. It is inadvisable to undertake lumbar-lumbo-sacral fusion for intervertebral disc degeneration when there are more than three adjacent vertebrae involved, and in any case operation should be confined to the indicated extent

Objectives

The objective of this study was to assess the association between whole body sagittal balance and risk of falls in elderly patients who have sought treatment for back pain. Balanced spinal sagittal alignment is known to be important for the prevention of falls. However, spinal sagittal imbalance can be markedly compensated by the lower extremities, and whole body sagittal balance including the lower extremities should be assessed to evaluate actual imbalances related to falls.

The progression of post-tubercular kyphosis in 61 children who received ambulatory chemotherapy was studied prospectively. The angles of deformity and kyphosis were measured for each patient at diagnosis, 3, 6, 9, 12 and 18 months later and every year thereafter for 15 years. During the course of the disease signs of instability appeared on the radiographs of some of the children. These were dislocation of the facets, posterior retropulsion of the diseased fragments, lateral translation of the vertebrae in the anteroposterior view and toppling of the superior vertebra. Each sign was allocated one point to create a spinal instability score. The influence on the progression of the deformity of the level of the lesion, the vertebral body loss, the number of segments involved, the angle of deformity before treatment and the spinal instability score was analysed. The mean angle of deformity at the start of treatment was 35°. This increased to 41° at 15 years. Progression occurred during the active phase of the disease and again after cure when variations in progression were observed. Type-I progression showed an increase in deformity until growth had ceased. This could occur either continuously (type Ia) or after a lag period of three to five years (type Ib). Type-II progression showed decrease in deformity with growth. This could occur immediately after the active phase (type IIa) or after a lag period of three to five years (type IIb). Type-III progression showed minimal change during either the active or healed phases and was seen only in those with limited disease. Multiple regression analysis showed that a spinal instability score of more than 2 was a reliable predictor of patients with an increase of more than 30° in deformity and a final deformity of over 60°. Since signs of radiological instability appear early in the disease, they can be reliably used to identify children whose spine is at risk for late progressive collapse. Surgery is advised in these cases

Aims

To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries.

Aims

The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications.

1. A relatively simple method of spinal fusion with internal splinting by screw fixation has been described. Complications have been few. 2. Emphasis is placed upon thorough removal of soft tissue, correct placement of screws of good length, the exposure of bleeding bone wherever possible in the fusion area, and the use of well packed cancellous bone. 3. There is enough spongy bone in one posterior superior iliac spine for an ordinary spinal fusion, and, if more is needed, the other is readily available through the same skin incision. Not only is cancellous bone more desirable than a massive cortical graft, but the leg is spared, allowing early walking and freedom from complications in the limb. 4. The lateral articulations are left intact. 5. Screw fixation has eliminated the use of external support except in spondylolisthesis, or when so much bone has been removed during laminectomy that good fixation cannot be obtained. 6. Early, sometimes immediate, relief of symptoms is usual after operation, and early walking with moderate activity is desirable. 7. When the operation was done for degenerative changes with no apparent defect in the laminae there was no radiological evidence of failure of fusion after operations at one level, but two failures were found after attempted fusions at multiple levels. 8. Root irritation from screw contact in two patients was due to faulty technique. A method of screw placement to avoid this complication is described and illustrated by radiographs and photographs of a cadaver specimen. 9. There has been no known instance of an adverse psychological effect from the use of screws. Rather, there has commonly been a lively and healthy interest shown in the factor which has allowed early activity